Healthcare Provider Details

I. General information

NPI: 1497016380
Provider Name (Legal Business Name): BLAKE EVAN GILBO M.S., LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: BLOSSOM EVONNE GILBO LPC, NCC

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 CRESCENT DR APT 1-1
CHAMPAIGN IL
61821-4270
US

IV. Provider business mailing address

206 W MARVIN AVE
FREDERICKTOWN MO
63645-1648
US

V. Phone/Fax

Practice location:
  • Phone: 217-974-9091
  • Fax: 217-974-9091
Mailing address:
  • Phone: 573-783-9248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number178.032745
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2015041412
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: